Nursing Presence During End-of-Life Care in the ICU with a Focus on Discontinuing Mechanical Ventilation

Abstract

Background: In certain jurisdictions around the world, the withdrawal of life-sustaining measures is part of end-of-life care in the intensive care unit.  Nurses, as primary providers of care, are often active participants in the coordination and actualization of the withdrawal process.  The withdrawal of mechanical ventilation is arguably one of the more complex aspects of the withdrawal process.

Aims: To review current published professional literature on the topics of intensive care nurses’ experiences of withdrawing of life-sustaining measures (Vanderspank et al., 2018) and withdrawing mechanical ventilation for compassionate means (Efstathiou et al., 2020), as well as explore the ways in which certain jurisdictions, namely Canada, have sought to standardize withdrawal of life-sustaining measures processes (Healy et al., 2020).

Methods: First, a detailed overview of the findings of a qualitative evidence synthesis on nurses’ experiences of withdrawing life-sustaining measures is presented (Vanderspank et a., 2018). Second, a systematic review and narrative synthesis of “perceptions, experiences and practices” of compassionate withdrawal of mechanical ventilation is described (Efstathiou et al., p. 1140X).  The latter review was registered with PROSPERO (CRD42018086495) and modelled on a Cochrane approach.  The search, with a phenomenon of interest being all forms of terminal withdrawal of mechanical ventilation, was executed in the following databases Medline and Medline in Process (via Ovid), Embase Class + Embase (via Ovid), Cochrane's Central Registry for Randomized Controlled Trials CENTRAL (via Ovid) and Cumulative Index of Nursing and Allied Health Literature (CINAHL, via EBSCOHost). Third, a Canadian initiative that included the development of a framework and a toolkit for the withdrawal of life-sustaining measures, was discussed. 

Findings: Specific to the Efstathiou et al. (2020) systematic review, 25 manuscripts were ultimately included in the review comprised of qualitative and qualitative designs as well as one Delphi study and encompassed findings from nine countries. The synthesized findings were reported under four themes.

Conclusions: Death and dying is a reality of critical care practice.  In jurisdictions where the withdrawal of life-sustaining measures is practiced, particular attention can be paid to the complexity of mechanical ventilation discontinuation for compassionate means. Critical care nurses demonstrate practice expertise related to the withdrawal of life-sustaining measures and their expert nursing knowledge and care has impact on the patient and family experience of death and dying in the intensive care unit. Regardless of jurisdictional practices, high-quality, end-of-life care is possible in the critical care context.

References

Efstathiou N, Vanderspank-Wright B., Vandyk A, Al-Janabi M, Deham Z, Sarti A, Delaney J, Downar J. Terminal withdrawal of mechanical ventilation in intensive care units: A systematic review and narrative synthesis of perceptions, experiences, and practices. Journal of Palliative Medicine. 2020;4(9): 1140-1164.  doi: 10.1177/0269216320935002.

Healy A, Hartwick M, Downar J, Keenan S, Lalani J, Mohr J, Appleby A, Spring J, Delaney J, Wilson LC, Shemie S. for Canadian Blood Services, the Canadian Critical Care Society, the Canadian Association of Critical Care Nurses, and the Canadian Society of Palliative Care Physicians. Canadian Journal of Anesthesia. 2020;67:1549 – 1556. https://doi.org/10.1007/s12630-020-01774-6

Vanderspank-Wright B, Efstathiou N, Vandyk AD. Critical care nurses’ experiences of withdrawal of treatment: A systematic review of qualitative evidence. International Journal of Nursing Studies. 2018;77:15-26. doi: 10.1016/j.ijnurstu.2017.09.012.